Development and evaluation of a teaching and learning approach
in cross-cultural care and antidiscrimination in university
⁎, Lucinda Brown
, Carmel Duff
, Pat Nesbitt
, Anne Hepner
School of Nursing & Midwifery, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125 Australia
School of Psychology, Deakin University, Victoria, Australia
Koorie Unit, Bendigo TAFE, PO Box 170, Bendigo 3552, Australia
Accepted 7 December 2012
Teaching and learning
Cross-cultural care and antidiscrimination
University nursing education
Background: Cross-cultural care and antidiscrimination are vital to ethical effective health systems. Nurses re-
quire quality educational preparation in cross-cultural care and antidiscrimination. Limited evidence-based
research is available to guide teachers.
Objectives: To develop, implement and evaluate an evidence-based teaching and learning approach in
cross-cultural care and antidiscrimination for undergraduate nursing students.
Design: A quantitative design using pre- and post-survey measures was used to evaluate the teaching and
Settings: The Bachelor of Nursing program in an Australian university.
Participants: Academics and second year undergraduate nursing students.
Methods: A literature review and consultation with academics informed the development of the teaching and
learning approach. Thirty-three students completed a survey at pre-measures and following participation in
the teaching and learning approach at post-measures about their conﬁdence to practice cross-cultural nursing
(Transcultural Self-efﬁcacy Tool) and about their discriminatory attitudes (Quick Discrimination Index).
Results: The literature review found that educational approaches that solely focus on culture might not be
sufﬁcient in addressing discrimination and racism. During consultation, academics emphasised the impor-
tance of situating cross-cultural nursing and antidiscrimination as social determinants of health. Therefore,
cross-cultural nursing was contextualised within primary health care and emphasised care for culturally
diverse communities. Survey ﬁndings supported the effectiveness of this strategy in promoting students'
conﬁdence regarding knowledge about cross-cultural nursing. There was no reported change in discrimina-
tory attitudes. The teaching and learning approach was modiﬁed to include stronger experiential learning
and role playing.
Conclusions: Nursing education should emphasise cross-cultural nursing and antidiscrimination. The study
describes an evaluated teaching and learning approach and demonstrates how evaluation research can be
used to develop cross-cultural nursing education interventions.
© 2012 Elsevier Ltd. All rights reserved.
There is no consensus about how cross-cultural care and
antidiscrimination are most effectively taught to nursing students.
Culturally appropriate care is vital to ethical and effective health
systems; therefore, nurses require education in cross-cultural care.
Although nurse scholars emphasise the need to focus on both culture
and antidiscrimination, few studies have addressed both constructs
or provided a thorough description of their teaching and learning ap-
proaches (Campesino, 2008; Nairn et al., 2004). We aimed to address
this gap by developing, implementing and evaluating an evidence-
based teaching and learning approach in cross-cultural care and
antidiscrimination contextualised within a social model of health.
The current study was undertaken in an Australian program of
three years duration leading to a Bachelor of Nursing emphasising
holistic nursing care understood as including the social, cultural and
biological determinants of health. This program was approved by the
Nurses Board of Victoria thereby meeting the requirements for full
Nurse Education Today 33 (2013) 1592–1598
⁎Corresponding author. Tel.: +61 3 9244 6960; fax: +61 3 9244 6159.
E-mail addresses: firstname.lastname@example.org (J. Allen),
email@example.com (L. Brown), firstname.lastname@example.org (C. Duff),
email@example.com (P. Nesbitt), annie@survivorﬁrstaidtraining.com.au
Tel.: +61 8341 64923.
Tel./fax: +61 3 9244 6159.
Tel.: +61 3 55 654594; fax: +61 3 55633548.
Tel.: +61 0431475143; fax: +61 0354341489.
0260-6917/$ –see front matter © 2012 Elsevier Ltd. All rights reserved.
Contents lists available at ScienceDirect
Nurse Education Today
journal homepage: www.elsevier.com/nedt
licensure as a registered nurse. The curriculum was focussed on pro-
viding students with strong foundations in the discipline of nursing
and an introduction to community nursing, mental health and acute
hospital care (Deakin University, 2004). In the ﬁnal year, the curricu-
lum emphasised advanced acute hospital care, chronic illness manage-
ment, aged care, and children's and family's care (Deakin University,
Following review, cross-cultural nursing was identiﬁed as a gap in the
curriculum and the community nursing subject required rewriting. Con-
sequently, the teaching and learning approach in cross-cultural nursing,
reported in the Methods and ‘Development and implementation of the
teaching and learning approach’sections, was established in the commu-
nity nursing subject and embedded within the social model of health.
We used the two relevant curriculum learning outcomes as a guide:
1. Explain the relationship between nursing and the social construc-
tions of health including primary health care
2. Based on available evidence create health promoting interventions
for individuals, families, and populations from culturally diverse
As the curriculum was based in holistic nursing care, we selected
the social constructivist model of health and theory of transcultural
nursing as the theoretical foundations for our teaching and learning
approach in order to focus on the importance of both culture and
antidiscrimination in nursing.
We understand health to be socially and culturally constructed.
Healthy people require healthy social, cultural and physical environ-
ments in addition to an absence of disease (Baum, 2011; McMurray
and Clendon, 2011). Health and medical treatment services are
contextualised within these broader social conditions as one of a
number of social determinants playing a vital role in health (Baum,
2011). Health is highly complex resulting from an interplay between
the social, cultural and biological determinants.
Previous research (Commission on the Social Determinants of
Health, 2008) has found that social and cultural determinants of health
affect health outcomes. Lack of culturally appropriate health care, dis-
crimination and racism are commonly experienced by minoritycultures
in Australia contributing to their poor health outcomes (Johnstone and
Kanitsaki, 2008). In other research on the ‘healthy immigrant effect’in
Canada, Newbold (2005) suggests that immigrants are at greater risk
of poor health than their native born counterparts because of discrimi-
nation and low socio-economic status.
Holistic care that addresses the social, cultural and biological de-
terminants of health is vital to ensuring equitable health outcomes
for all peoples. Quality cross-cultural care that explicitly targets struc-
tural barriers to health such as discrimination is necessary to achieve
health equity. Therefore, cross-cultural and antidiscrimination care, in
addition tocare targeting the social determinants of health are expected
standards of the nursing profession (ICN, 2007a, b)andexpectedcore
components of undergraduate curricula (Campesino, 2008).
In Australia, where this study was undertaken, cross-cultural care and
antidiscrimination in nursing education are particularly pertinent due to
the culturally diverse Australian community. Twenty-seven per cent of
Australians are born overseas (Australian Bureau of Statistics, 2009–10)
and they experience poorer health outcomes than their Anglo-Australian
counterparts (Johnstone and Kanitsaki, 2008). Australian Aboriginal
peoples comprise 2.5% of the Australian population (Australian Bureau
of Statistics, 2009) and experience extremely poor health outcomes, ev-
ident in the life expectancy gap of up to 17 years less than any other
Australians (Commonwealth of Australia, 2012). Poor health outcomes
of Australians born overseas and Australian Aboriginal peoples indicate
the socially unjust and subtle effects of discrimination in addition to
other poor social determinants of health.
Nurses are not able to directly overcome many structural barriers
to health, such as poverty and low socio-economic status. However,
nurses are able to provide culturally appropriate antidiscriminatory
health care and understand the complex effects of the social determi-
nants of health (International Council of Nurses, 2007a, b; McMurray
and Clendon, 2011). Educational preparation in cross-cultural nursing
and antidiscrimination contextualised in a social model of health is
required to meet these professional expectations. Yet, culture, anti-
discrimination and social models of health are absent from many
Australian undergraduate nursing curricula (Keleher et al., 2010;
Pinikahana et al., 2003). In part this may be due to the lack of consen-
sus regarding how cross cultural nursing should be taught.
Transcultural nursing is central to the debate among nurse aca-
demics regarding the recommended approach to teaching and learning
in cross cultural nursing. Transcultural nursing is a theory of nursing
concerned with comparing differences and similarities between c ultures
regarding caring values and life practices to predict care needs of indi-
viduals and promote culturally ﬁtting care (Leininger and McFarland,
2002). In transcultural nursing, cross-cultural care is nurses' under-
standing and application of the relevant culture's caring actions, health
care information and knowledge to effectively meet a person's health
care needs (Leininger and McFarland, 2002). Transcultural self-efﬁcacy
is part of transcultural nursing. It refers to conﬁdence in performing
transcultural skills necessary for the nursing process: assessing, plan-
ning, implementing and evaluating culturally competent care (Jeffries,
2006). Past research has found that teaching and learning interventions
for nursing students based in transcultural nursing and transcultural
self-efﬁcacy are effective in promoting students' conﬁdence to practise
cross-cultural care (Allen, 2010; Lim et al., 2004). However, few
studies have speciﬁcally evaluated discrimination and racism in
nursing students following participation in cross-cultural educa-
tion (Allen, 2010). In one study (Hagey and Mackay, 2000), covert
racism was identiﬁed among some nursing students following
completion of cross-cultural education, suggesting that discrimina-
tory and racist beliefs are challenging to address in teaching and
Research Question and Aims
How can teaching and learning in cross-cultural nursing and
antidiscrimination be supported in nursing students?
We aimed to address this question by
1. Developing and implementing an evidence-based teaching and
learning approach in cross-cultural care and antidiscrimination,
as contextualised within a social model of health
2. Evaluating students' self-report attitudes reﬂecting transcultural
self-efﬁcacy, and antidiscrimination before and after participating
in the teaching and learning approach
3. Providing evidence-based recommendations for curriculum
The teaching and learning approach was developed from a process
of consultation with academics and from a literature review. A quantita-
tive design using pre and post-survey measures was used to evaluate
the teaching and learning approach. The study design is summarised
in Fig. 1.
Developing the Tteaching and Learning Approach
Using the curriculum learning outcomes as our guide, we developed
the teaching and learning approach from a process of consultation
and debate to draft speciﬁc learning objectives, consider the approach
1593J. Allen et al. / Nurse Education Today 33 (2013) 1592–1598
to be implemented and deliberate the assessment of students' learning.
We also completed a literature review to identify evidence.
The process of consultation and debate, captured in the minutes of
meetings over 2008 and 2009, was conducted with all ﬁve academics
with expertise in community nursing and with responsibility for the
community nursing subject, who co-authored this paper. The ﬁrst
author sent an invitation and a project proposal to the four other aca-
demics teaching the community nursing subject. All four agreed to
participate. These academics were experienced community nurses
with a range of practice, teaching and research experience in Australia
and internationally including in general district nursing, public health
nursing, school nursing, rural nursing, midwifery, and maternal and
child health nursing. All participants were Anglo-Australians, female
and aged between 40 and 55 years. All were registered nurses or reg-
istered midwives with postgraduate qualiﬁcations in at least one of
the following: nursing, public health, education, psychology or mid-
wifery. Meetings took place each month over 2008 and in the ﬁrst
6 months of 2009 between participants face to face and/or by tele-
phone link up.
A circular process ensued during monthly meetings, whereby
learning objectives were drafted about how to achieve each curricu-
lum learning outcome in clear operational terms. Related discussion
points were identiﬁed, debated and negotiated. All teaching and
learning materials, activities and assessment tasks required for imple-
mentation of the teaching and learning approach were tabled for
discussion. These discussions were noted in the minutes and sent to
all participants for familiarisation prior to the next meeting (Annells
and Whitehead, 2007). Robust debate resulted during which opinions
and ideas were thoroughly tested.
This process of consultation and debate was juxtaposed against
the ﬁndings of a literature review completed by the ﬁrst author iden-
tifying published evaluation evidence in cross-cultural care and anti-
discrimination teaching and learning. This literature review has been
published elsewhere (Allen, 2010).
Evaluation of Students' Conﬁdence in Cross-cultural Care and
All students enrolled in second semester 2009 were invited to com-
plete a postal survey before participating in the teaching and learning
approach at pre-measures and after participating in the teaching and
learning approach at post-measures. This survey evaluated their trans-
cultural self-efﬁcacy, or conﬁdence in practising transcultural nursing
skills, and their attitudes about cultural differences. The university
student database was used to identify students and demographic infor-
mation including their age, gender, country of birth, domestic/interna-
tional status, and campus location.
The pre-survey was mailed to all enrolled students two weeks
prior to the commencement of classes in second semester 2009 with
a copy of the Plain Language Statement and an introductory letter.
Upon completion of the teaching and learning approach at the end of
second semester 2009, a post-survey was mailed to the same students.
The response rates on the pre and post-surveys were low at 13.2%.
Therefore observations made in class during teaching by academics be-
came an additional important source of information.
This survey comprised two valid and reliable self-report measures:
the Transcultural Self-efﬁcacy Tool (TSET) (Jeffries, 2006) and the
Quick Discrimination Index (QDI) (Ponterotto et al., 2002). The TSET
(Jeffries, 2006) captures perceived conﬁdence in practising transcul-
tural nursing skills on a cognitive subscale regarding knowledge
about the ways cultural factors may affect care for people from differ-
ent cultural backgrounds, and on a practical subscale regarding conﬁ-
dence in interviewing a person about their culture (Jeffries, 2006). The
QDI (Ponterotto et al., 2002) captures prejudicial attitudes directed
towards racial minority groups. Two QDI subscales, appraising general
attitudes towards racial diversity and affective attitudes towards more
personal contact with racial diversity, were included in the survey.
Survey data were scored in accordance with the authors' guide-
lines (Jeffries, 2006; Ponterotto et al., 2002) with higher scores
reﬂecting more of the construct. All survey data and demographic
data were entered into a Statistical Package for the Social Sciences
Version 17 (SPPS) database for analysis. Data were analysed using
SPSS Frequencies,Descriptives,Explore,Scale,and Compare Means.
Demographic data were analysed for frequencies and where data
were on a continuous scale, such as age, descriptive statistics were
computed (mean, standard deviation) and means compared using in-
dependent samples ttest. Comparisons of gender, country of birth,
domestic/international status, and campus location were undertaken
using chi square analysis for independence. Pre- and post-data on a
continuous scale (subscales of the TSET, QDI) were appraised using
paired samples t-tests.
Modiﬁcation of the Teaching and Learning Approach
The academics who developed the teaching and learning approach
considered the evaluation ﬁndings and observations they had made
during teaching and modiﬁed the approach for inclusion in subse-
each month over
Developing the T&L
•Survey at pre measures and
following participation in the T&L
approach at post measures
•Survey measured students’:
•Confidence to practice cross -
cultural nursing (Transcultural
•Discriminatory attitudes (Quick
Student evaluation of
cross-cultural nursing &
findings during further
modified the T&L
approach for inclusion
Modification of the
Fig. 1. Summary of the study design.
1594 J. Allen et al. / Nurse Education Today 33 (2013) 1592–1598
Approval for the pre- and post-surveys was sought and obtained
from the university ethics committee thereby safeguarding students'
anonymity and conﬁdentiality. Nursing students participated volun-
tarily in the surveys following explanation of the study using a Plain
Language Statement that provided information regarding their right
to decline to participate in the study without any effect on their studies.
They provided implied consent by returning a completed survey.
Implementation of the teaching and learning approach
The teaching and learning approach in cross-cultural care and
antidiscrimination was developed and implemented in relation to
the two curriculum learning outcomes. The literature review ﬁndings,
learning objectives, implemented teaching and learning approach
and implemented assessment tasks are summarised in Table 1.
The social constructivist model of health and theory of transcul-
tural nursing form the frameworks underpinning the teaching and
learning approach in cross-cultural care and antidiscrimination devel-
oped and implemented in this study. The primary teaching methods
we used to implement this approach were those of class debate and
discussion, and case scenarios for experiential learning. We expected
that by including learning activities where students were required to
problem solve and provide nursing interventions to overcome cultural
and social barriers to health in each case scenario, they would learn at
an experiential level about the complexities of cross-cultural care and
antidiscrimination. We further anticipated that this process would
enable students to start to differentiate between people and their
communities, and the social conditions in which they lived. Lectures
presented relevant theoretical material. Tutorials required students to
apply knowledge to problem solve relevant case scenarios from real-
world community nursing practice. Practicum laboratories were oppor-
tunities for students to learn related skills such ascross-cultural assess-
ment and care. The teaching and learning approach was taught over
eight weeks of lectures (one hour per week), tutorials (2 h per week)
and laboratories (1 h per week) resulting in 32 h of teaching on campus
and 40 h of clinical placement; a total of 72 h of face-to-face classes/
It was expected that the curriculum learning outcomes as listed in
Table 1 would be met by challenging students' attitudes and beliefs
concerning culture and diversity, Australian Aboriginal health, and so-
cial factors inﬂuencing health including those particular to Australian
Aboriginal peoples such as colonialism and racism. We expected that
Summary of development and implementation of teaching and learning approach in relation to curriculum learning objectives.
Literature review ﬁnding Learning objectives Implemented T&L approach Implemented assessment
Curriculum learning outcome 1
Explain the relationship between nursing and the social constructions of health including primary health care
•Evidence indicates that T&L approaches
are required to promote understanding
of how social structures and determinants
including discrimination inﬂuence health
care practices and systems
Students' understanding of health requires
challenging through discussion and
•promote understanding of the complex
social and cultural factors, in addition
to biological factors, affecting health.
•develop understanding of discrimination
as a social determinant of health
•develop understanding of the subtle
and powerful effects of the social
determinants of health
•identify the social determinants of health
that present barriers to health for
particular peoples in the community
Classroom debate supported by readings
and group discussion, discussion
questions focussed on
What social factors inﬂuence health?
How these social factors inﬂuence health?
How social factors present barriers to health
for particular groups in the community?
The role of discrimination and racism in
health and health care services
Nursing as a social determinant of health
How nursing practice and interventions can
overcome some structural barriers to health
for people from
1. culturally diverse backgrounds
2. Australian Aboriginal backgrounds
Online multiple choice tests
sampling students' knowledge
related to each topic domain
Curriculum learning outcome 2
Based on available evidence create health promoting interventions for individuals , families, and populations from culturally diverse backgrounds
•Evidence indicates that T&L approaches
based in transcultural nursing are
effective in promoting cross-cultural
skills and attitudinal change
•T&L approaches focussed on culture
alone may not be effective in changing
•Evidence indicates that discriminatory
beliefs are difﬁcult to change in nursing
and health professional students
Students' cross-cultural learning should be
supported by comparing differences and
similarities between cultures regarding
caring values and life practices to predict
care needs of individuals and promote
culturally ﬁtting care
Students' perceived conﬁdence in practising
transcultural nursing skills should be
developed and supported
Students' attitudes and beliefs concerning
culture and diversity should be identiﬁed
Students' attitudes and beliefs about
Australian Aboriginal health require
identiﬁcation to promote self-reﬂection,
appreciation of cultural differences and
understanding of discrimination.
Classroom debate, group discussions and
experiential learning techniques promoted
by the use of two ‘real life’case scenarios:
1. The community nursing care of an elderly
man and his wife from a migrant
background (Mr and Mrs Lipari)
2. Community nursing care in relation to
Australian Aboriginal health and the
Close the Gap policy of the Australian
Government (both case scenarios are
summarised in Table 2).
Reading material, case notes and
audio-visual material prompt discussion,
debate and self-reﬂection.
Focus on health promoting nursing
interventions that are culturally
appropriate and overcome some
structural barriers to health in relation
to both case scenarios
Focus on each student reﬂecting on their
own beliefs and attitudes in relation to
The care of Mr and Mrs Lipari
Care to support the health of Australian
One written assignment of 1500
words regarding how community
nursing skills and roles in
cross-cultural care could inﬂuence
the health of diverse communities
in Australia (summative
assessment, 60% weighting)
Students were required to complete
a one week clinical placement with
a community nurse providing care
in the community (summative
1595J. Allen et al. / Nurse Education Today 33 (2013) 1592–1598
the learning outcomes would be facilitated by classroom debate and
group discussions about two case scenarios, one about the community
nursing care of an elderly man and his wife from a migrant back-
ground and one about Australian Aboriginal health and the Close the
Gap policy of the Australian Government (summarised in Table 2).
Reading material, case notes and audio-visual material prompted dis-
cussion and debate in class. Academics expected that this approach
would promote students' self-reﬂection regarding their own culturally
and socially determined values and biases, and also how those inherent
to health care systems and the greater community might affect nursing
care and health care for different peoples in Australia and account for
disparities in health outcomes.
The primary health care principles of access and equity guided
teaching and learning in both scenarios with emphasis on how nursing
interventions might overcome some structural barriers to health and be
All 251 students enrolled in the subject were invited to participate in
the pre- and post-surveys. In total, 61 students returned a pre-survey
and 55 returned a post-survey comprising response rates of 24.3% and
21.9% respectively. However, of all 251 students, only 33 completed
both a pre- and post-survey, resulting in a response rate of 13.2%.
Demographic data for the total group of 251 students are presented
in Table 3. These students were an average age of 25 years (SD 8 years,
range 18–65 years). Most students (n= 230, 91.6%) were female, and
born in Australia with seven (2.8%) identifying as Aboriginal/Torres
Strait Islander Australians.
People completing a pre- and post-survey were compared with
the entire group of students on age, born in Australia/elsewhere and
campus location. There were no signiﬁcant differences between the
total group of students and those completing pre- and post-surveys
on place of birth or campus location. It was not possible to undertake
comparisons for gender because there were not enough males in the
pre/post sample (n= 4) to meet assumptions for chi square analysis.
The age of those completing pre and post-surveys (m= 29.6 years
sd= 10.3) was compared with the mean age of the entire student
group (m= 25.17 years sd = 8.158) and was found to be signiﬁcantly
different (t= −2.7 (df 37.4) p = 0.01) suggesting that older students
were more likely to complete both surveys than younger students
Pre- and post-measures were compared on all dependent variables
using pairedsamples t-tests. The alpha level was set at 0.05 signiﬁcance.
These data are presented in Table 4. The TSET cognitive subscale captur-
ing students' perceived conﬁdence (self-efﬁcacy) in performing cross-
cultural nursing care (knowledge skills) is signiﬁcantly different
between pre- and post-measures, indicating that students consid-
ered that they had improved in this domain. All other measures
were not signiﬁcant, indicating that there was no change.
Modiﬁcation of the Teaching and Learning Approach
During follow-up consultation meetings between the academics,
all evaluation ﬁndings were considered and the teaching and learning
approach was modiﬁed. These modiﬁcations included greater focus on
practical skills in cross-cultural nursing including interviewing skills
and working with interpreters, and the inclusion of experiential learn-
ing activities such as role play, during which one student played the
role of a culturally diverse client and another student played the role
of a nurse. The teaching content about Aboriginal health and written
assessment task 2 were changed to include greater focus on the social
determinants speciﬁcally affecting AustralianAboriginal peoples'health
such as discrimination and racism.
In this study, a teaching and learning approach in cross-cultural
care and antidiscrimination was developed and implemented. Case
scenarios, group discussion and experiential learning were emphasised
and have been found to be effective in meeting learning outcomes in
other studies (see for example; Kaplan and Ura, 2010; Johnson and
Mighten, 2005). Evaluation ﬁndings indicated that students' conﬁdence
in knowledge about cross-cultural nursing had improved following
completion of the teaching and learning approach. Evaluation ﬁndings
further suggested no change in students' conﬁdence in practical skills
in cross-cultural nursing, or in students' antidiscrimination attitudes.
Academics emphasised the importance of situating cross-cultural
nursing and antidiscrimination teaching and learning in a social
model of health. This strategy was in response to the literature review
(Allen, 2010) and debate between nurse scholars in transcultural
anursing (Jeffries, 2006; Leininger and McFarland, 2002)andthose
Summary of case scenarios 1 and 2.
Case scenario 1 Mr and Mrs Lipari
Mr Lipari is an 89-year-old man living in his own home with his wife, Marie, who is
85 years old and is his main carer. He has multiple chronic health problems. Their
local GP is concerned about their ability to remain safely in their own home and
has made a referral to community nursing. Neither Mr nor Mrs Lipari speaks English
and with exception to their GP, they are reluctant to access health services.
Case scenario 2 ‘Close the gap’policy in relation to Australian Aboriginal health
In 2008, as the ﬁrst item of business in the Australian parliament, the then Prime
Minister Kevin Rudd made a speech apologising to the thousands of Aboriginal
people who had been forcibly removed from their families and communities prior
to the early 1970s in accordance with government laws of the time (Apology to
the Stolen Generations, Commonwealth of Australia, 2012). In this speech, Kevin
Rudd introduced new government policy aiming to substantially improve the
social determinants of health for Aboriginal peoples with the overall goal of equal
life expectancy between Aboriginal and non-Aboriginal Australians.
Students' demographic data (N=251).
Variable Frequency n(%)
Female 230 (91.6)
Male 21 (8.4)
Country of birth
Australia 190 (75.7)
China/Hong Kong 14 (5.6)
Zimbabwe 8 (3.2)
India/Sri Lanka 6 (2.4)
Other 33 (13.1)
Domestic 217 (86.5)
International 34 (13.5)
Mean scores for outcomes at pre- and post-measures (n = 33).
Scale Pre-m (sd) Post-m (sd) t Df Sig⁎
101.21 (16.42) 108.30 (18.27) −2.165 32 0.04⁎
207.28 (37.31) 218.31 (38.98) −1.76 31 0.09
23.73 (4.53) 23.09 (4.07) 1.12 32 0.27
15.52 (4.15) 15.85 (4.16) −0.68 32 0.50
⁎Signiﬁcance at .05.
1596 J. Allen et al. / Nurse Education Today 33 (2013) 1592–1598
arguing that social structural barriers to health for culturally diverse peo-
ples also require strong emphasis in nursing education (Campesino,
2008; Papadopoulos, 2006; Culley, 2001). aPast research has found
alimited description and deﬁnition of teaching and learning ap-
proaches as implemented and evaluated in cross-cultural care and
aantidiscrimination. This study addresses this gap in the research and
provides an exemplar of a teaching and learning approach for consider-
ation by others aiming to improve undergraduate nursing curricula.
We focus our discussion here on the student evaluation ﬁndings,
cross-cultural knowledge and practical skills (TSET), and discriminatory
beliefs (QDI) in order to support the modiﬁcations to the implemented
teaching and learning approach. The ﬁnding of improved self-efﬁcacy
regarding cross-cultural knowledge as captured by the TSET cognitive
subscale suggests developing conﬁdence in cross-cultural knowledge
among these students following participation in the teaching and learn-
ing approach. This ﬁnding replicates previous research suggesting
that transcultural nursing educational approaches are effective in devel-
oping cross-cultural nursing skills in undergraduate nursing students
(Allen, 2010). The two case scenarios, considering care requirements
for an elderly man and his wife from migrant backgrounds and health
outcomes related to the social context of Australian Aboriginal peoples,
included group discussion and problem solving in regard to the effects
of cultural background and social determinants on current health issues
and nursing care. This may have facilitated students' self-efﬁcacy in
knowledge of the effects of culture on care as captured by the cognitive
subscale of the TSET (Jeffries, 2006). Notably, the absence of change in
the practical subscale of the TSET suggests that students' self-efﬁcacy
concerning more practical elements of cross-cultural nursing such
as in interviewing skills required additional attention. Hence, we in-
cluded this teaching focus in the modiﬁed teaching and learning
The absence of signiﬁcant differences between pre- and post-
measures on the QDI indicated the challenge of addressing discrimina-
tory beliefs in teaching and learning. This reiterates the conclusions of
Hagey and Mackay (2000) that racist beliefs are difﬁcult to change fol-
lowing participation in cross-cultural nursing education. Discrimina-
tion is a social determinant of health shaping the health conditions
of nursing clients as well as the attitudes, beliefs and practices of nurs-
ing students. The absence of change in discriminatory beliefs among
our students is perhaps not a surprising ﬁnding immediately following
completion of cross-cultural education given the complexities of overt
and covert discrimination within society and culture.
We developed the teaching and learning approach in the current
study to focus speciﬁcally on discrimination and racism in Australian
Aboriginal health using the ‘Close the Gap’case scenario. This scenario
and the ‘Apology to the Stolen Generations’speech were highly topical
in the Australian media in 2008 and 2009 and we expected that they
would stimulate discussion and strong emotional responses in rela-
tion to students' own attitudes and beliefs about discrimination and
racism. As reported by teachers in consultation meetings continuing
during the implementation of the teaching and learning approach,
the class focussed on viewing the ‘Apology to the Stolen Generations’
speech by Kevin Rudd and subsequent discussion and debate were
extremely challenging. This was due to the racist views expressed by
several students. Although challenging for teachers and many stu-
dents, this indicated that the strategy was effective in raising emotion-
ally difﬁcult, confronting and potentially covert issues for debate and
discussion among both students and teaching staff. Many domestic
and international students directly and thoughtfully challenged the
racist views raised by some students in class. Teachers noted that stu-
dents born either in an African country or with parents from an African
country were particularly active in these discussions. Importantly,
differences in ‘culture’and experiences of discrimination were shared
experiences for many students. The culturally diverse nature of nursing
students in many classes contributed substantially to challenging de-
bate and discussion about racism.
Academics developing the teaching and learning approach agreed
to continue with the content and focus of the class and topic about
discrimination and racism as it was considered valuable learning
enabling students to test their perspectives, beliefs and at times
‘taken for granted’privileges regarding culture, race and discrimina-
tion with each other. Assessment task 2 was modiﬁed in accordance
with this ﬁnding to focus on the social and cultural determinants of
Australian Aboriginal peoples' health, and meaningful nursing inter-
ventions. We anticipated that greater emphasis on the social and
structural determinants of health for Australian Aboriginal communi-
ties and consideration of participative nursing interventions to sup-
port these communities' health would provoke further reﬂection
and ‘testing’of internal values and beliefs about discrimination.
There are a number of limitations in the current study. Low re-
sponse rates on the survey may indicate limited interest among
these students to participate in a survey at pre- and post-measures.
The university requests students to complete online student satisfac-
tion surveys for every subject upon completion of each semester and
students may be over surveyed. Findings from the survey cannot be
claimed to have been caused by the teaching and learning approach.
Other factors may account for the change in scores on the TSET such
as learning in other subjects undertaken at the same time. The discrim-
ination scores as measured on the QDI cannot be claimed to represent
all students in this cohort.
The study described an implemented and evaluated teaching and
learning approach and demonstrates how evaluation research can be
used to develop cross-cultural nursing and antidiscrimination educa-
tion interventions. There are implications of these ﬁndings for curric-
ulum developers and for evaluation methods. Teaching and learning
approaches in nursing education should emphasise both cross-cultural
nursing and antidiscrimination. Indigenous health issues need to be
addressed to ensure that pertinent historical factors such as those relat-
ed to colonialism and racism are made overt. Evaluation techniques to
assess student learning, attitudes and related processes require careful
attention in order to appraise teaching effectiveness. In view of the co-
vert nature of discrimination and racism, observations made during
teaching are valuable sources of information about relevant learning
processes. The study addresses a gap by explicitly evaluating both cul-
ture and antidiscrimination following cross-cultural nursing education
providing an exemplar to guide teachers.
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